Excellent Wall Street Journal article highlights potential importance of nurse practitioners to future of health care

October 11, 2004 -- Today the Wall Street Journal ran an extraordinarily good piece by Andrew Blackman exploring the increasingly important role nurse practitioners (NP's) play in primary care and other areas. The lengthy article, which focuses on a group of New York City NP's, is entitled "Is There a Doctor in the House? Perhaps not, as nurse practitioners take on many of the roles long played by physicians." How good is Blackman's piece? Let us count the ways.

Any article about NP's will note their growing prominence, but this one reports that nurse-run primary care practices "may be critical to the future of health care in the U.S." The story explains that NP's are not only quicker and cheaper to train than physicians, but that their holistic, thorough, preventative approach may be uniquely suited to care for an aging population suffering long-term illnesses. The piece clearly describes the different approach of NP's, using expert quotes and specific examples, explaining how the nurses' greater focus on patients' environments, psychological factors and practical issues leads to effective, holistic solutions to long term problems, such as asthma.

At the core of the piece is its description of the Columbia Advanced Practice Nurse Associates (Capna), a pioneering NP-run practice founded in 1994 by the Columbia University School of Nursing. As the piece reports, Capna was the first nurse-run clinic in the U.S. to win full privileges to admit patients to hospitals, and the first to gain insurance compensation at the same rate as physicians. The article also includes effective and extensive quotes from Capna NP's and patients. One patient, a public relations professor, praises the comprehensive, patient, psychologically aware approach of the NP's, at the same time unloading significant criticism on the many physicians she had seen before finding Capna, stating that many had "no bedside manner" and just wanted to get patients out of the office without providing sufficient explanation of what was going on. Another patient who is an investment manager comes up with a killer analogy for physician-NP collaboration, comparing it to his own experience as a business school graduate in partnership with a lawyer, a collaboration of two professions that approach issues in different ways but work well together. Mr. Blackman actually closes the piece with a quote from this patient, who correctly suspects that there are differences in the way nurses and physicians are trained, and suggests that perhaps "the future of health care is to find a way to combine the different skills of each one." In fact, to a significant extent this issue is also critical to the present state of health care, and it applies not only to NP's, but to all nurses and other health care professionals whose valuable contributions are often overlooked in a physician-obsessed media and cultural environment.

The Journal piece is unusually good in other ways. It makes clear the educational requirements for NP's and RN's, a seemingly simple thing that is surprisingly rare in mainstream media articles. The article describes the four-year "doctor of nursing practice" program that Columbia will introduce next year to more fully prepare students for independent practice and new functions in hospitals. Blackman describes some of the hurdles that NP's have yet to overcome, including legislative limits on their autonomy and the huge pay disparity with physicians doing comparable work, suggesting that one factor in this is that "for many people the image of a nurse is still that of a junior partner to the all-knowing physician." The piece notes the ongoing concerns of some that NP's might miss a diagnosis that a physician would catch, but clearly states that "studies have shown that when it comes to patient outcomes, nurse practitioners are just as good as doctors." He cites a 2000 JAMA study involving Capna NP's, and also refers to other studies "over the past 20 years [that] have shown comparable patient outcomes." The piece relies heavily on expert nurse comment, particularly by Columbia nursing dean and Capna founder Mary Mundinger and University of Pennsylvania nursing professor Ann O'Sullivan. Blackman even includes quotes from NP pioneer Loretta Ford, who "started the first nurse-practitioner program with a physician, Henry Silver, at the University of Colorado in 1965." Finally, the piece makes very clear that NP's today are not just filling gaps, but winning over patients who could easily be seeing physicians instead--a point Mundinger emphasizes in noting that she chose Capna's exclusive Madison Avenue address precisely so the NP's could compete directly with physicians. Apparently they can: Capna, which now also has a practice in the city's Washington Heights neighborhood, has more than 2,000 patients with 90 more patients joining each month.

Of course, we can always find some suggestions for improvement. The piece might have described some of the intense legislative conflicts about the scope of NP and other APRN practice with physicians who are concerned about (depending on whom you believe) either patient safety or a very real threat of competition. The piece does not explicitly describe the other types of APRN's, such as certified nurse midwives and certified nurse anesthetists. The piece might have made clearer that much of its description of the different training and care model of NP's is actually true of registered nurses generally, and that RN's bring this complementary practice focus to bear for the benefit of their patients in many settings, doing extensive patient advocacy and education every day. This is even more important in this era of denursification, where RN's have nearly vanished from the outpatient setting. Moreover, though we rarely have cause to urge the physician-obsessed media to include more comment from physicians, the piece might have benefited from at least a quote or two from physicians about issues such as NP-physician collaboration, scope of practice, and the role of NP's in the future of health care. If nothing else, it might have been instructive (and fairer) to hear a physician response to the public relations professor's highly critical remarks. Finally, there is the use of the term "doctor" in the headline and the piece. We think the use of the "doctor in the house" cliche in the headline is appropriate and effective, as it grabs people but its underlying assumptions are instantly contradicted by the subhead and the article itself. We are somewhat more troubled by the use of the term "doctor" rather than "physician" in some other parts of the piece. The piece rightly addresses Mundinger and O'Sullivan as "Dr. ____," but does not clarify that they are nurses with doctorates, not physicians. In our view, it is best to clarify this by including credentials (e.g., Mary Mundinger, RN, DrPH) and to refer to physicians only as physicians, not "doctors." Of course, you might argue that this is truly a vision of the future, a future in which the fact that a nurse can have a nursing doctorate is so unremarkable and so widely understood that there is no need to explain it.

See Andrew Blackman's article "Is There a Doctor in the House? Perhaps not, as nurse practitioners take on many of the roles long played by physicians" in the October 11, 2004 issue of the Wall Street Journal.

Send letters of thanks for an excellent job covering nursing to Andrew Blackman at andrew.blackman@wsj.com